The defendant is charged [in count
___] with unauthorized conveyance of items into a (correctional / humane)
institution or to an inmate. The statute defining this offense reads in
pertinent part as follows:

any person not authorized by law
who conveys or passes, or causes to be conveyed or passed, into any
(correctional / humane) institution or the grounds or buildings thereof, or to
any inmate of such an institution who is outside the premises thereof and known
to the person so conveying or passing or causing such conveying or passing to be
such an inmate any (controlled drug / intoxicating liquors / firearm / weapon /
dangerous instrument / explosive / United States currency / rope, ladder, or
other instrument or device for use in making, attempting or aiding an escape)
shall be guilty.

For you to find the defendant guilty
of this charge, the state must prove the following elements beyond a reasonable
doubt:

Element 1 - Without
authorizationThe first element is that the
defendant was not authorized by law to do any of the acts enumerated in the
statute.

Element 2 - Conveyed
unauthorized items into institutionThe second element is that the
defendant conveyed the following unauthorized item[s] into <insert name of
facility>.

<Insert one or more of the
following:>

any controlled
drug. "Controlled
drugs" are defined by statute as those drugs which contain any quantity of a
substance which has been designated as subject to the Federal Controlled
Substances Act, or which has been designated as a depressant or stimulant drug
pursuant to federal food and drug laws, or which has been designated by the
Commissioner of Consumer Protection as having a stimulant, depressant or
hallucinogenic effect upon the higher functions of the central nervous system
and as having a tendency to promote abuse or psychological or physiological
dependence, or both. Such controlled drugs are classifiable as
amphetamine-type, barbiturate type, cannabis- type, cocaine-type,
hallucinogenic, morphine-type and other stimulant and depressant drugs.
Specifically excluded from controlled drugs and controlled substances are
alcohol, nicotine and caffeine.

"Firearm"
means any sawed-off shotgun, machine gun, rifle, shotgun, pistol, revolver, or
other weapon, whether loaded or unloaded, from which a shot may be discharged.

"Weapon" includes
anything used or designed to be used in destroying, defeating, or injuring an
enemy.

"Dangerous
instrument"
means any instrument, article or substance which, under the circumstances in
which it is used or attempted or threatened to be used, is capable of
causing death or serious physical injury. "Serious physical injury" means
physical injury which creates a substantial risk of death, or which causes
serious disfigurement, serious impairment of health or serious loss or
impairment of the function of any bodily organ. It is important to note
that the article need not be inherently dangerous; all that is required is
that the article was capable of causing death or serious physical injury
under the circumstances in which it was used. Any article or substance,
without limitation and even though harmless under normal use, may be found
by you to be a dangerous instrument if, under the circumstances of its use
or threatened or attempted use, it is capable of producing serious physical
injury or death. The state need not prove that in fact death or serious
physical injury resulted, only that the instrument had that potential under
the circumstances.

"Explosive" is any
chemical compound, mixture, or device that functions by explosion.

any United States
currency.

any rope, ladder or
other instrument or device for use in making, attempting, or aiding an escape.
The statute provides that "[t]he unauthorized conveying, passing or possession
of any rope or ladder or other instrument or device, adapted for use in making
or aiding an escape, into any such institution or the grounds or buildings
thereof, shall be presumptive evidence that it was so conveyed, passed or
possessed for such use." This means that if you find that the defendant
conveyed or passed into the institution or had in (his/her) possession while in
the institution any rope or ladder or other instrument or device adapted for use
in making or aiding an escape, then you may conclude, but are not required to,
that the defendant intended to use it for the purpose of making or aiding an
escape, provided of course that the inference drawn complies with the standards
for inferences as explained in connection with my instruction on circumstantial
evidence.

The state alleges that the defendant
(conveyed or passed / caused to be conveyed or passed) these items <insert as
appropriate:>

into <insert
name of facility> by means of <insert specific allegations>.

to <insert name
of inmate> while <insert name of inmate> was outside the premises of
<insert name of facility> and the defendant knew that <insert name of
inmate> was an inmate of <insert name of facility>.

Element 3 - Correctional
institutionThe third element is that <insert
name of facility> is a (correctional / humane) institution. For the
purposes of this offense, institution includes the grounds and any buildings on
the grounds. <Insert the appropriate definition:>

A "humane
institution" is any (state mental hospital / community mental health center /
treatment facility for children and adolescents / any facility or program
administered by the (Department of Mental Health and Addiction Services /
Department of Mental Retardation / Department of Children and Families)).1

Conclusion

In summary, the state must prove
beyond a reasonable doubt that 1) the defendant's actions were not authorized by
law, 2) the defendant conveyed or caused to be conveyed <insert the object
conveyed> into <insert name of facility>, and 3) <insert name of
facility> is a (correctional / humane) institution.

If you unanimously find that the state
has proved beyond a reasonable doubt each of the elements of the crime of
conveying unauthorized items into an institution, then you shall find the
defendant guilty. On the other hand, if you unanimously find that the state has
failed to prove beyond a reasonable doubt any of the elements, you shall then
find the defendant not guilty.
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